2. Nerrilyn Agius 2
Does your documentation protect you?
Your documentation is a
reflection of you.
Excellent
Very good
Average
Below average
Poor
OUTCOME:
You will look after yourself
Choose to document well and choose to be prepared when bad things happen
3. Nerrilyn Agius 3
Documentation Protects you
Provides evidence of:
Competent staff
Teamwork
Procedure informed practice
Write in everyday language
4. Nerrilyn Agius 4
All aged care/disability services must have efficient and
effective
reporting and documentation protocols.
Accurate information is essential to ensure clients needs are
met and effective and quality services are delivered.
Accurate recording and reporting is essential to ensure that
accountability for services and funding requirements are
maintained at all times.
…… “if it isn’t written down, then it didn’t happen”
5. Nerrilyn Agius
Rules for reporting/documentation
Documentation is the official record of
services
that are proposed/provided to a client
All workplaces will have their own
methods
of reporting and recording
5
6. First rule of reporting:
All reports and documents must use OBJECTIVE
language.
this means……… describe
→ ONLY what you saw or heard (were told) ←
“THE FACTS”
Objective language is important for
accuracy, accountability and legal
purposes.
Nerrilyn Agius 6
7. Nerrilyn Agius
Extract from the report Re-written objectively
Sofina was up all night screaming and
creating havoc
Peter cannot be trusted to stay in the car
with out a staff member, as he provokes
the other clients
Richard refuses to discuss moving into an
aged care facility and becomes
aggressive when the matter is raised. He
is unrealistic about his understanding of
his abilities to take care of himself
Mary appears distressed when the
support worker arrives in her home and
will not comply with any request the
support worker makes
7
8. Nerrilyn Agius 8
Reporting and documenting
• Verbal (spoken):
- telephone
- face-to-face
• Non-verbal (written):
- progress notes
- case notes
- hazard and incident forms
- care plans
10. Nerrilyn Agius
Maintain documentation and client records
Every client’s documentation and daily occurrences, daily
tick/observation charts, reports etc must be completed daily as
required.
Records of daily/weekly visits to HACC clients must be completed at
each visit.
Any changes in client situations or circumstances must be documented
and reported immediately.
Information on existing clients must be readily available when required.
New information should be placed to the front of previous information.
10
11. Nerrilyn Agius
Updates of client information should be added to their files immediately
it is received e.g. results of pathology tests
Information must be kept current e.g. change of address. NOK
Out of date information may lead to the wrong course of action being
taken e.g. resistance to some antibiotics, development of lactose
intolerance , food allergies, incorrect treatment may be given
Client files can become very full. When this occurs, some of the older
information can be removed and filed separately but must remain within
easy access for future reference – for the duration of the period that the
organisation is caring for them.
11
12. Nerrilyn Agius
When completing client notes and written reports the
general rules of reporting/documentation are:
• Writing must be neat and easy to read.
• Use the correct spelling and grammar.
• Describe everything using OBJECTIVE language
• Do not leave blank lines between entries. Rule a line through
gaps – prevents tampering/unauthorised additions
• Check that you have the correct client file!
• Use BLACK ink. NEVER use pencil
• Write the date and time at the beginning of every entry
• Use 24 hour clock time
12
13. Nerrilyn Agius
• Sign all entries with signature (must be
legible) and title (if applicable). A. Carer
PCA
• Document ASAP.
• Follow the flow of information.
• Late entries – if you forget to include some
information, or further information needs to
be added – date and time and state
“Additional” at commencement
• No criticism
•
13
14. Nerrilyn Agius
• If you make a mistake draw a single line through the error
and initial the correction. Mark the mistake as “ME”
(mistaken entry) or “Entered in error” NEVER USE
WHITE-OUT OR CORRECTION TAPE
• Record your own actions only.
• If information/instructions are received by phone then
state this in the notes
• Do not alter someone else’s entries
• Only use abbreviations and terminology that is used by
your organisation – avoids any
misunderstandings/mistakes
• Legible
14
15. Nerrilyn Agius 15
Relevant documentation
Duty of Care
Care support plans
Goals – completion, barriers, outcomes
Choice, control, independence, re-enablement,
strengths
Your role
Procedures / guidelines-will guide you
Risks
What risks are you responsible for managing?
16. Nerrilyn Agius 16
Documenting Risks & Incidents
Legal and complaints protection
The Facts – ‘what and when’ did you –
see, hear, do (actions) and communicate
What prevention strategies were in place
(Facts – see or hear)
What have you put in place (Actions)
17. Nerrilyn Agius 17
Key points
1. Remember your audience
2. Document Facts. Not what you think or feel
3. Structure you documentation to reflect the clients care /
support
4. Document when a client chooses to not follow advice,
waives risk, refuses care. Consequences and choices
5. Document the management of risk – prevention strategies
6. Allocate time for documentation – I didn’t have time is not a
defence
18. Nerrilyn Agius 18
Storage of records
All client records must be stored securely and safely.
Privacy and confidentiality must be maintained at all times.
Workplace policy for storage of records must be followed at all times.
Client records must be kept by the organisation for several years
after they cease to be clients e.g. following their death
19. VERBAL REPORTING
• Be factual
• Be clear
• Be concise
• Follow legal requirements, Duty of Care
• Meet organizational requirements, formally go through each client in
a set pattern of reporting or only exception reporting.
• Report these vague statements and write how you could change
these into something objective
• Everything is terrible
• TAFE is great
• I feel sad
• I feel happy
When completing client notes and written reports the general rules of reporting/documentation are:
Writing must be neat and easy to read. This avoids confusion, difficulty working out what it says, misunderstandings and time wasting
Use the correct spelling and grammar. Ask if you are unsure, or use a dictionary
Describe everything using OBJECTIVE language
Do not leave blank lines between entries. Rule a line through gaps – prevents tampering/unauthorised additions
Check that you have the correct client file!
Use BLACK ink. NEVER use pencil as this is not considered a permanent record for legal purposes
Write the date and time at the beginning of every entry
Use 24 hour clock time - avoids confusion between am and pm
Sign all entries with signature (must be legible) and title (if applicable). A. Carer PCA
Document ASAP. This ensures accuracy and avoids forgetting important facts.
Follow the flow of information. Refer to previous entries and comment if required. Cover one topic at a time, in order of sequence.
Late entries – if you forget to include some information, or further information needs to be added – date and time and state “Additional” at commencement
If you make a mistake draw a single line through the error and initial the correction. Mark the mistake as “ME” (mistaken entry) or “Entered in error” NEVER USE WHITE-OUT OR CORRECTION TAPE
Record your own actions only. If another care worker has something to report ask them to write this themselves. If it is necessary to record the actions of another person, make sure you include their name.
If information/instructions are received by phone then state this in the notes
Do not alter someone else’s entries
Only use abbreviations and terminology that is used by your organisation – avoids any misunderstandings/mistakes
Sign all entries with signature (must be legible) and title (if applicable). A. Carer PCA
Document ASAP. This ensures accuracy and avoids forgetting important facts.
Follow the flow of information. Refer to previous entries and comment if required. Cover one topic at a time, in order of sequence.
Late entries – if you forget to include some information, or further information needs to be added – date and time and state “Additional” at commencement
If you make a mistake draw a single line through the error and initial the correction. Mark the mistake as “ME” (mistaken entry) or “Entered in error” NEVER USE WHITE-OUT OR CORRECTION TAPE
Record your own actions only. If another care worker has something to report ask them to write this themselves. If it is necessary to record the actions of another person, make sure you include their name.
If information/instructions are received by phone then state this in the notes
Do not alter someone else’s entries
Only use abbreviations and terminology that is used by your organisation – avoids any misunderstandings/mistakes
